Clinical Guidelines for Phimosis

Last updated 12/23/2022

Managing Phimosis

These clinical recommendations were created by NORMUK to aid in the diagnosis and management of phimosis among medical professionals and health authorities.

These recommendations are the first of a set that will also include recommendations for the management of balanoposthitis and other conditions that may have an impact on the foreskin.

Normal Anatomy and Development

The prepuce, also known as the foreskin, provides an anatomical covering over the glans and is a vital, natural component of the penis. It is a unique junctional mucosa with specialized innervation that serves as erogenous tissue. The prepuce contains thousands of nerve endings, Meissner and Vater-Pacini corpuscles, and specialized sensory receptors such Merkel cell discs.

The sensory receptors of the preputial mucosa’s ridged band may be a component of the reflex’ afferent limb. In a newborn male infant, the prepuce has not fully developed. Foreskin re-tractability and separation from the glans happen at various ages.

There is no time limit for this, and full re-tractability frequently does not develop until well into adolescence. A prepubescent child’s non-retractable foreskin is not a sickness and doesn’t need to be treated.

Diagnosis

Phimosis is not the inability of the foreskins function to retract throughout childhood. Innocent and temporary, ballooning during micturition is a typical component of development and doesn’t need to be treated. Scarring of the prepuce tip is considered to be true phimosis and is typically caused by Balanitis Xerotica Obliterans (BXO).

According to a recent report, there are 0.4 occurrences of pathological phimosis per 1000 boys annually, or 0.6% of males by the age of 15. In adulthood, the non-retractable foreskin may also be referred to as phimosis.

Treatment

It is important to recognize and respect a child’s normal non-retractile foreskin. Patients and their parents should be warned against attempting a forced or early retraction of the foreskin and against using too much soap.

Following a diagnosis of phimosis, therapeutic options include full or partial circumcision, preputial plasty and manual stretching.

Topical corticosteroids like Hydrocortisone are also frequently used in conjunction. Surgery should only be done as a last option after trying more conservative therapy first. Below are descriptions of the various therapy choices.

Topical Steroids

According to several studies, topical prednisone can safely and successfully treat phimosis in 80–90% of patients. 2-3 times per day, the exterior and interior of the foreskin tip should be treated with betamethasone cream 0.05%. If the foreskin does not become retractile after 3 months, the treatment should be stopped as useless.

Conservative Surgery

For the non-retractable foreskin of an adult or adolescent, several plastic repairs are possible. These include preputial plasty, which entails making a dorsal, longitudinal incision into the foreskin’s constriction band.

The Buck’s fascia is exposed by spreading the underlying tissue with artery forceps, and the incision is then stitched transversely with absorb-able sutures. The prepuce can be kept after this operation, which has lower morbidity rates than circumcision.

Circumcision

A child’s circumcision is traumatic, as it is with any surgery. It should only be used as a last option because it is practically irreversible. It has been thought that the only common absolute indication for circumcision is pathological phimosis brought on by BXO. However, BXO and Lichen Sclerosis Atrophicans are similar (LSA).

According to reports, circumcision is useless in either preventing or treating BXO. Topical corticosteroids, topical testosterone, and carbon dioxide laser therapy all work on BXO. One study demonstrates the efficacy of long-term antibiotic use, but it is unclear whether this is attributable to antimicrobial activity.

Cautions for Circumcision

Since circumcision is practically permanent, it should only be used as a last option. All of the following patient requirements must be satisfied before a circumcision can be done.

• Have a valid therapeutic justification for circumcision, after trying and failing with conservative treatment.
• Have an understanding of the consequences of circumcision and be willing to undergo the procedure.
• Have recognized that there is a 2% probability of significant problems following circumcision.
• Have a supportive friend or family member spend the night with them.

References

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